Tropical Health Matters

The Lancet Infectious Diseases had a recent special issue on malaria in pregnancy (MIP).  Of special interest is an article by Greenwood et al. (2007) that outlines some of our knowledge gaps in MIP and hence the need for future research.

One important research question is “The importance of malaria as a cause of maternal mortality in areas of medium or high malaria endemicity.”  These data would go a long way in advocacy efforts to increase support for funding MIP programs.

Another challenge is, “Finding new drugs for the treatment of malaria in pregnancy.” The authors point to the demise of chloroquine and SP. While come countries are including ACTS as accepted treatment in the second and third trimesters, studies are not available to confirm safety.  Designing drug research with pregnant women will remain a serious ethical problem, but one that cannot not be shied away from. Another crucial drug issue is “New drugs for IPTp.”   Drug efficacy studies have been done mostly with children, but the rapidly declining effectiveness of SP in treating childhood malaria naturally raises concern about SP for IPTp.

A basic assumption in MIP control programs is that intervention must be integrated within quality antenatal care.  The authors raise the need for, “Identification of optimum delivery strategies for scaling up the use of insecticide-treated nets and IPT,” that consider viable alternatives (see for example, item on community directed interventions in previous blog).  They note the low level of ANC utilization in many countries. This is coupled with the fact that the dropout rate between IPTp1 and IPTp2 is often substantial.  One therefore questions whether effective MIP control should be in the business of strengthening the quality of ANC services or find ways to deliver MIP control services in the most direct and safe way to pregnant women.

Of particular concern is the fact that women register for ANC late, and even if ITNs/LLINs are available at ANC, they could not protect most women in their first trimester as seen in the attached graph of ANC registration from Oyo State, Nigeria. The cultural elements of this problem include beliefs that one should protect a pregnancy by not letting others know until it shows and perceptions that since pregnancy is ‘normal’, one should not disrupt regular work routines to attend ANC.  Further social and operational research is definitely needed to find a MIP control package delivery mechanism that really reaches women.

The challenge of these and other suggestions for future research rest on funding sources.  In addition to the usual expected sources such as foundations and international development agencies, one would hope that those applying for Global Fund malaria grants would build operations research into their monitoring and evaluation systems so that countries can learn from real life experiences.

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